Job Information
Southeast Health Utilization Review Nurse in Dothan, Alabama
Southeast. Always the right career direction.
Job Description Summary
The Utilization Review Nurse screens medical records in accordance with contractual agreement and regulatory requirements for medical necessity on admission and continued stay in the acute care setting. The UR case manager collaborates with all components of the healthcare system, managing appropriate use of acute care to aid in the achievement of quality outcomes, fiscal responsibility, and patient satisfaction.
Job Description
Essential Functions
Perform admission and continued stay reviews of all inpatients and outpatient/observation patients in a bed; at times, this may be retrospective.
Perform precertification on procedures ordered while patients are hospitalized.
Issue required Medicare/Medicaid notifications of medical necessity changes to patients while hospitalized.
Issue notifications of non-coverage letters to patients if received during hospital stay.
Document clear billing notes into the EMR payer communications navigator to avoid billing denials.
Perform medical necessity denial appeals.
Maintain a close, collaborative relationship with the medical staff to promote continuity of care and avoid delays in service.
Must demonstrate basic knowledge of discharge planning needs
Direct Reports (positions supervised)
None
Qualifications
Minimum Education Required
Associates degree in Nursing
Current RN license in the state
Minimum Education Preferred
- Bachelor’s degree or higher in Nursing
Minimum Experience Required
Two (2) years acute care experience
Must pass Blue Cross Blue Shield Iterator Reliability Test with 90% within six (6) months of hire
Minimum Experience Preferred
Three (3) years acute care experience
One (1) year utilization review experience
Required Skills/Abilities
Demonstrates advanced computer skills (ability to generate reports, graph trends).
Clinical knowledge and experience in the care of patients with multiple and complex diagnoses, disease process, and care needs.
Ability to prioritize work and meet deadlines.
Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge.
Ability to develop leadership skills and to serve as a role model for clinical staff.
Ability to lead and actively participate in multidisciplinary teams.
Ability to work independently within a team structure.
Shift
DayShift Details
8:00 am - 4:30 pm
FTE
1
Type
Regular
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Equal Employment Employer
Southeast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.
